04-0824_ALL AMERICAN ASPHALT_Certificate of InsuranceCERTO F
Ii #
iM? DATE IMMIUD/YY) -.
8/24/04
PRODUCER-
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Calco Ins Brokers 8 Agent
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Lie. No. OB29310
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
500 City Pkwy West, Ste. %500
COMPANY
Orange CA 92868-2946
(714) 937-1824
A Arch Specialty Insurance Co.
INSURED
COMPANY
All American Asphalt
B Hartford Fire Insurance Co.
PO Box 2229
COMPANY
Corona, CA 92878-2229
C Great American insurance Ca
COMPANY
Seabright Insurance Co
.:CowWait
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THEPOLICY PERIOD
INDICATED,NOT W ITHSTANDING ANY REOUIREMENT,TERMOR CONDITION OFANYCONTRACT OR OTHER DOCUMENT W ITHRESPECT TO W HICHTHIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN
MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICYEFFECTIVE
DATE MIDDIYY)
POLICY EXPIRATION
DATE(MMIDDIYY)
LIMITS
A
GENERALLIABILITY
326PP0535900
8/01/04
8/01/05
GENERAL AGGREGATE $ 2,000,000
PRODUCTS-COMP/OP ADD $ 2,000,000
X
COMMERCIAL GENERAL LIABILITY
ADDITIONAL INSURED 6
CLAIMS MADE FX OCCUR
PRIMARY WORDING APPLIES
PERSONAL A ADV INJURY $ 11000,000
OWNER'S& CONTRACTOR'S PROT
ONLY IF REQUIRED BY
EACH OCCURRENCE S 11000,000
FIRE DAMAGE (Any one fire) $ 50,000
X
4100,000 SIR
CONTRACT
MED EXP (Any one person) $
B
AUTOMOBILE
LIABILITY
72UENSK5491 K2
8/01/04
8/01/05
COMBINED SINGLE LIMIT S
X
ANY AUTO
1,000,000
BODILY INJURY $
(Per person)
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY $
HIRED AUTOS
NON OWNED AUTOS
(Per accident)
PROPERTY DAMAGE $
GARAOELIABILITY
AUTO ONLY - EA ACCIDENT $
OTHER THAN AUTO ONLY:
ANY AUTO
N/A
EACH ACCIDENT S
AGGREGATE $
C
EXCESS LIABILITY
TUE5950076
8/01/04
8/01/05
EACH OCCURRENCE $ 10,000,000
AGGREGATE $ 10,000,000
UMBRELLA FORM
Is
OTHER THAN UMBRELLA FORM
D
WORKERS COMPENSATION AND
BB1040243
8/01/04
8/01/05
X STATUTORY LIMITS
EMPLOYERS'LIABLITY
EACH ACCIDENT $ 11000,000
THE PROPRIETOR/ )( INCL
PARTNERS/EXECUTIVE
DISEASE - POLICY LIMIT $ 11000,000
DISEASE EACH EMPLOYEE S 11000,000
OFFICERS ARE: EXCL
OTHER
N/A
DESCRIPTION OF OPERATIONSILOCATIONBIVEHICLESISPECIAL ITEMS
RE: Rancho Viejo Road Rhabilitation, Malaspina Road to 1700 Feet South (CIP No. 120)
'10 days notice for nonpayment of premium 2ax• so
GERT9FIGATE HpLLlSR
GA:10E.W.AT*
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
City of San Juan Capistrano
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDWW{ION(X90(NXAL
Public Works Dept.
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Attn: Brian Perry
BXR)gMIKMWW)MYAW)DOMYMKK)NWAtXXNWKtlNKMU) WU(WXXKM)LWX)NWIMWXXXX
32400 Paseo Adelanta
OFT(X90[XXXMWXXNWMXX70WD)MR1AKMXXWXXY)gWN11W(X9(NXXNWANNNKXWAXOM
AUTHORIZED REPRESENTATIVE
San Juan Capistrano, CA 92675
053011
ACORG18S•S 9183
AGpRA�#7APUAAT9f�N X583:
CERTIFICATE: 208/001/ 02138
c 11 . •
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET ADDITIONAL INSURED
SECTION III — WHO IS INSURED is amended to include as an additional insured those persons or
organizations who are required under a written contract with the Named Insured to be named as an additional
insured, but only with respect to liability arising out of your operations, "your work", or premises owned by or
rented to you.
All other terms and conditions of this Policy remain unchanged.
City of San Juan Capistrano and its elected and appointed officials
PROJECT:
Rancho Viejo Road Rehabilitation, Malaspina Road to 1700 Feet South (CIP No. 120)
Endorsement Number:
This endorsement is effective on the inception date of this policy unless otherwise stated herein
(The information below is required only when this endorsement is issued subsequent to the preparation of the
policy.)
Policy Number: 32GPP0535900
Named Insured: All American Asphalt
Endorsement Effective Date: 8/1/04
00 CGL0006 00 02 04 cAMy Oocs\ALL\Endt.doc
CALIFORNIA PRELIMINARY NOTICE
(California Civil ecriort 3097 as amended by Senate Bi(( 1379 [Chapter 3961'ive January 1, 1978)
Notice to Property Owner -If bills are not paid if full for a labor, services, equipment or materials famished or to he furnished, a mechanic's lien leading to the loss, through court
foreclosure proceedings, of all or part of your property being so improved may be placed against the property even though you have paid your contractor in full. You may wish to
protect yourself against this consequence by (1) Requiring your contractor to famish a singed release by the person or firm giving you this notice before making payment to your
contractor, or (2) Any method or device that is appropriate under the cirarmstances. Other than residential homeowners of dwellings containing fewer than five units,
TO:
CITY OF SAN JOAN CAPISIRPNJ
X GwNER
Name of person or firm famishing
REPUTED OWNER
32400 PASEO ADELANTO
OR
NM£
PUBLIC AGENCY
SAN JUAN CAPISPRAN), CA 92675
Dated September 28, 2004
OCSS JOB NUMBER 434002
YOU ARE HEREBY NOTIFIED
That the undersigned has furnished or will famish
labor, services, equipment or materials of the following
description.
STRIPING, STENCILS, SIGNS, SANDBLASTING, MARKERS, THERMOPLASTIC, GUARDRAIL, BARRICADE
For the building, structure or
other work of improvement located at
RANCHO VIEJO ROAD REHABILITATION MALASPINA ROAD TO 1700 FEET
SOUTH OF MALASPINA ROAD
THE NAME AND ADDRESS OF THE PERSON WHO CONTRACTED
FOR THE PURCHASE OF SUCH LABOR, SERVICES, EQUIPMENT OR
MATERIAL
IS: SEE BELOW
ALL AMERICAN ASPHALT (JOB 16211)
TO:
mtr P.O. BOX 2229
OR
CORS, CA 92878-2229
S
ti
E
Name of person or firm famishing
labor, semee equipment or matenal
NAddress
NM£
D
w
AEIFESS
E
By
IE(�
R
IL
NONE REPORTED
This acknowledges remipt on
Trust funds to which supplemental fringe benefits are payable
NAME
ti
7
nmais
NM£
w
AEIFESS
Materia( men not required tojumish
the above
ORANGE COUNTY STRIPING SEF
183 NORTH PIXLEY STREET -
I i1fifil=2111 i s 101 J M d 7_TrImUi it
INC. - LIC.#346095
GE, CA 92868
Date September 28, 2004
NOTICE
TO CONSTRUCTION LENDER ONLY
Estimated total price of the labor, services,
equipment or materials described hereon.
ACKNOWLEDGMENT OF RECEIPT OF PRELIMINARY 20 -DAY NOTICE
(Sectio. 3097.1, Calif Civil Code)
(Date)
(Date this acknowledgment is eaeared)
detach
creepy of Nis prelaninary 20 -day notice at
(Address where Notice received)
(Signature ofperson acknowledging-cceipp with title ofacknowfedgmem is made
on behalfof another person)
and mtam same to sender
-CA- Iola --i,' I °-"i-t